GW1-2022-08495_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L.Oliver 14r WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3002-A 57,59 f`' 63,65 f°
117 ft. et
NC Well Contractor Certification Number 15 OUTER CASING(for multi-cased^:wells)OR LINER(if a •licable)
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 f`' 38 f" 1 6 1/4" ' SDR21 PVC
16:IIVNER CASING OR TUBING(geothermal closed-loop)'-
2.Well Construction Permit#• 10012529 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): . I ft. ft. in.
17:SCREEN
Water Supply Well:
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply(shared) 18 GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f`' 38 f`' Bentonite Pour 23)501b Bags
Monitoring E]Recovery fL ft.
Injection Well:
ft. ft.
Aquifer Recharge DGmundwater Remediation
19t.SAND/GRAVEL'PACK(if applicable)
>
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer `20 DRILLING LOG attach additional sheets if necessary)
E2ft
TO DESCRIPTION(color,hardness,soi0rock t e, ram size,etc.)Geothermal(Heating/Cooling Return) Other(ex lain under#21 Remarks) 11 f`- Brown Cla4.Date Well(s)Completed:3-29-2022 Well ID# 32 ft' Brown Sand/Rock
5a.WellLocation: 200 ft' Granite
Fred Stubblefield . ft.
Facility/Owner Name Facility ID#(if applicable) ft, ft.
4908 Carmel Club Dr. Charlotte 28226 ft. ft.
Physical Address,City,and Zip ft. ft. `
Mecklenburg 211-671-16 21.REMARKS-
County Parcel Identification No.(PIN) marS I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.55.917 N 80.49.138 W
4-7-2022
6.Is(are)the well(s)JoPermanent or OTemporary Signature of Cenified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constnicted in accordance
7.Is this a repair to an existing well: rlYes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the welt owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fa-multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 12 (ft.) Division of Water Resources,Information Processing Unit,
If ivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 Method of test. Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 12oZ completion of well construction to,the county health department of the county
where constructed.
Four GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016